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A Human Factors Analysis and Classification System (HFACS) Examination of Commercial Vessel Accidents

By Forrest J. Griggs


Approved for public release; distribution is unlimitedHuman Systems Integration ReportHuman error has been identified in an estimated 80 per cent of all commercial and military maritime accidents. Crew sizes on commercial merchant ships are characteristically smaller than military vessels. Commercial merchant ships rely on automated technology in order to reduce crew sizes. Since next generation naval ship designs are leveraging automated technology in order to reduce manning, an examination of commercial ship accidents is warranted. Two independent raters coded 518 findings from 48 maritime mishap reports using the Department of Defense Human Factors Analysis and Classification System (HFACS) taxonomy. Inter-rater reliability was calculated using Cohen’s Kappa and a final result of 0.72 was determined for HFACS Level I. HFACS analysis identified relationships among the HFACS levels and collision, allision, and grounding accidents. Logistic regression analysis identified six patterns stemming from latent conditions and active failures. This was used to develop a modified hazard analysis to identify how latent conditions aligned in the accident event chain, and to propose intervention measures. The research concluded that a maritime version of HFACS should be adopted to improve the reliability of classifying causal factors. Additionally, by employing human factors post-accident research the Navy may be able to develop possible intervention strategies for the fleet.Lieutenant, United States Nav

Topics: Human Systems Integration, Safety, Mishaps, Human Factors, Human Factors Analysis and Classification System (HFACS)
Publisher: Monterey, California. Naval Postgraduate School
Year: 2012
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